At Blue Cross Blue Shield of North Dakota (BCBSND), we are committed to supporting quality member care by ensuring that our providers maintain and share medical records in a manner that is current, detailed, and organized.
Overview
BCBSND requires health records to be maintained in a way that facilitates communication and coordination of care. Our health record standards ensure that practitioners and providers in our network comply with these requirements. We distribute these standards to all practitioners and appropriate staff members who handle medical records, including organization staff and any staff in the medical practitioner office.
Key Components of this requirement
- Health Record Content and Organization: Health records must include comprehensive information such as history and physicals, allergies and adverse reactions, problem lists, medications, and documentation of clinical findings and evaluations for each visit.
- Confidentiality: Medical records must be stored securely, with access limited to authorized personnel only. Staff members receive periodic training in maintaining the confidentiality of member information.
- Sharing Health Record Information: Providers are required to share health record information as appropriate and in accordance with professional standards. This ensures timely communication, coordination, and continuity of care.
Purpose and Scope
The purpose of this requirement is to support quality member care and ensure that our members receive medically necessary and appropriate care related to the purpose of their visit. Providers are expected to submit documentation specific to the patient and the individual encounter, which helps ensure appropriate reimbursement and avoids inflated claims. This policy applies to the entire BCBSND provider network and practitioners.
Documentation Standards
Each health record must include the following information as needed:
- History and physicals
- Allergies and adverse reactions
- Problem list
- Medications
- Documentation of clinical findings and evaluation for each visit
- Preventive services/risk screening
Confidentiality and Security
Medical records must be stored securely, and only authorized personnel should have access to them. Staff members who handle medical records must receive periodic training on maintaining the confidentiality of member information.
Sharing Health Record Information
Providers are required to share health record information as appropriate and in accordance with professional standards. This ensures timely communication, coordination, and continuity of care.
For more detailed information, please refer to BCBSND Provider Manual.
